MEDICAL POLICY I. POLICY POLICY TITLE FOOT ORTHOTICS AND OTHER PODIATRIC APPLIANCES POLICY NUMBER MP 6.028

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1 Original Issue Date (Created): 7/1/2002 Most Recent Review Date (Revised): 5/29/2018 Effective Date: 7/6/2018 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY APPENDIX I. POLICY Orthopedic shoes and other supportive devices of the feet are considered medically necessary ONLY when they are an integral part of a leg brace. These shoes and devices are described as Oxford shoes (L3224, L3225), other shoes, e.g. high top, depth inlay or custom for non-diabetics, etc. (L3649), heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600-L3640). Inserts and other shoe modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-L3595) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Foot orthotics other than those that are an integral part of a brace may be considered medically necessary only when they are a benefit of a member s contract, to meet specific needs of the patient, and prescribed by a physician for the below criteria: For Adults and Children [Any ONE Condition]: Chronic plantar fasciitis Calcaneal bursitis (chronic only) Calcaneal spurs (heel spurs) Chronic ankle instability Inflammatory conditions (i.e., sesamoiditis; submetatarsal bursitis; synovitis; tenosynovitis; synovial cyst; osteomyelitis; rheumatoid disease; and osteoarthritis) Medial osteoarthritis of the knee (lateral wedge insoles) Musculoskeletal/arthropathic deformities (including: deformities of the joint or skeleton that impairs walking in a normal shoe; e.g., bunions, hallux valgus, talipes deformities, tendonitis, pes cavus deformities, hammertoes, anomalies of toes) Neurologically impaired feet (including: neuroma; tarsal tunnel syndrome; ganglionic cyst; and neuropathies involving the feet, including those associated with diabetes) Page 1

2 Vascular conditions (including: poor circulation, peripheral vascular disease, Buerger's disease, and chronic thrombophlebitis) Note: Both adults and children must have symptoms associated with the particular foot condition (foot orthotics are considered not medically necessary when the foot condition does not cause symptoms); and have failed to respond to a course of appropriate conservative treatment (e.g., physical therapy, injections, strapping, anti-inflammatory medications). (Orthotics should not be considered first line therapy.) ONE of the following per member per calendar year is considered medically necessary: 1. No more than 1 pair of custom-molded shoes (including inserts provided with the shoes) and 2 additional pairs of inserts; or 2. No more than 1 pair of depth shoes and 3 pairs of inserts (not including the noncustomized removable inserts provided with such shoes). Medical necessity criteria for replacements of or modifications to existing customized shoes is based on the same criteria noted for the shoe itself. Replacement of a pair of shoes, or modifications, should be based on necessity (e.g., worn out, loss of effectiveness), not for convenience or style change. Due to wear and tear with normal use, orthotics may need refurbishing periodically, every 1 or 2 years. Replacement of orthotics is generally not necessary more often than every 2 years. Foot orthotics are considered not medically necessary when these criteria are not met such as for back or knee pain (other than medial osteoarthritis), corns and calluses, and lower leg injuries as there is insufficient evidence to support a conclusion supporting the health outcomes or benefits associated with this item. The provider requesting/ordering the DME should be a provider with whom the member has established a relationship and is involved in the ongoing care of the member and the condition for which the DME/orthotic is prescribed. Cross-reference: MP Therapeutic Shoes for Persons with Diabetes MP Ankle-Foot and Knee-Ankle-Foot Orthoses II. PRODUCT VARIATIONS TOP This policy is applicable to all programs and products administered by Capital BlueCross unless otherwise indicated below. FEP PPO* Page 2

3 *Refer to FEP Service Benefit Plan for Orthopedic Shoe exclusion. The FEP Medical Policy manual can be found at: III. DESCRIPTION/BACKGROUND TOP Foot orthotics may be accommodative or functional. Accommodative foot orthoses are custom or non-custom inlays fabricated for the purpose of providing relief from callosities and pressure points, and maintaining the integrity of the longitudinal arch and/or the metatarsal heads. Functional foot orthoses are foot plates fabricated from plaster molds of the feet or electronic (computer) imaging in a semi-weight bearing or non-weight bearing, neutral position, with corrections built in to prevent abnormal compensation during the gait cycle. Orthopedic shoes are shoes used to prevent or correct disorders of the bones, joints, muscles, ligaments and cartilage of the legs and feet. Custom-made orthopedic shoes are shoes fabricated over special modified lasts in accordance with prescriptions and specifications to accommodate gross or greater foot deformities or shortening of a leg at least 1 and 1/2 inches or greater. Custom-made orthopedic shoes may be necessary when a physician or podiatrist determines that the severity of the foot condition is such that a lesser means (e.g., inlay shoes, shoe modifications, etc.) cannot adequately compensate for the deformity or there is a leg discrepancy length at least of 1 and 1/2 inches in length or greater. Initial custom-made orthopedic shoes, lasts, and patterns normally are obtained when the severity of the foot disability requires the physical presence of the member for casts, measurements, and possible trial fittings. A shoe modification is a medically prescribed alteration(s) to a shoe(s) to accommodate minor foot deformities, disabilities, or leg shortening of less than 1 and 1/2 inches. Shoe modifications (e.g., rocker soles, shoe buildups, metatarsal bars, shoe stretching, Thomas heels, tongue pads, velcro closures, modified lacers, etc.) may be applied to personally purchased shoes, upon medical determination of need, to compensate for minor foot deformities. Depth inlay shoes are pre-fabricated shoes with a higher toe box to accommodate for hammer toes and other deformities. This shoe may also accommodate the insertion of special inserts. These shoes are traditionally made of plastizote or other pressure absorbent material. Inlay shoes may be necessary after it has been determined that shoe modifications will not accommodate the foot deformity and that an insole or additional space is necessary. Page 3

4 IV. DEFINITIONS TOP INSERTS - Medically necessary inserts are those that are total contact, multiple densities, removable inlays that are directly molded to the member's foot or a model of the member's foot and are made of a material suitable for the member's condition. METATARSAL BARS: These are exterior bars that are placed behind the metatarsal heads in order to remove pressure from the metatarsal heads. The bars are of various shapes, heights, and construction depending on the exact purpose. OFFSET HEELS: This is a heel flanged at is base either in the middle, to the side, or a combination, that is then extended upward to the shoe in order to stabilize extreme positions of the hind foot. RIGID ROCKER BOTTOMS: These are exterior elevations with apex positions for 51 % to 75 % distance measured from the back end of the heel. The apex is a narrowed or pointed end of an anatomical structure. The apex must be positioned behind the metatarsal heads and tapering off sharply to the front tip of the sole. Apex height helps to eliminate pressure at the metatarsal heads. The steel in the shoe ensures rigidity. The heel of the shoe tapers off in the back in order to cause the heel to strike in the middle of the heel. ROLLER BOTTOMS (SOLE OR BAR): These are the same as rocker bottoms, but the heel is tapered from the apex to the front tip of the sole. WEDGES (POSTING): Wedges are either of hind foot, fore foot, or both and may be in the middle or to the side. The function is to shift or transfer weight upon standing or during ambulation to the opposite side for added support, stabilization, equalized weight distribution, or balance. V. BENEFIT VARIATIONS TOP The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital BlueCross for benefit information. VI. DISCLAIMER TOP Capital BlueCross s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical Page 4

5 advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital BlueCross considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. CODING INFORMATION TOP Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: HCPCS Code A9283 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3031 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 Foot pressure off loading/supportive device, any type, each Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each Foot, insert, removable, molded to patient model, Spenco, each Foot insert, removable, molded to patient model, Plastazote or equal, each Foot insert, removable, molded to patient model, silicone gel, each Foot insert, removable, molded to patient model, longitudinal arch support, each Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each Foot insert, removable, formed to patient foot, each Foot, insert/plate, removable, addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, each Foot, arch support, removable, premolded, longitudinal, each Foot, arch support, removable, premolded, metatarsal, each Foot, arch support, removable, premolded, longitudinal/metatarsal, each Foot, arch support, nonremovable, attached to shoe, longitudinal, each Foot, arch support, nonremovable, attached to shoe, metatarsal, each Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each Hallus-valgus night dynamic splint, prefabricated, off-the-shelf Foot, abduction rotation bar, including shoes Foot, abduction rotation bar, without shoes Foot, adjustable shoe-styled positioning device Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each Orthopedic shoe, oxford with supinator or pronator, infant Orthopedic shoe, oxford with supinator or pronator, child Orthopedic shoe, oxford with supinator or pronator, junior Orthopedic shoe, hightop with supinator or pronator, infant Page 5

6 HCPCS Code L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3260 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 Orthopedic shoe, hightop with supinator or pronator, child Orthopedic shoe, hightop with supinator or pronator, junior Surgical boot, each, infant Surgical boot, each, child Surgical boot, each, junior Benesch boot, pair, infant Benesch boot, pair, child Benesch boot, pair, junior Orthopedic footwear ladies shoe oxford each Orthopedic footwear, ladies shoe, depth inlay, each Orthopedic footwear ladies shoe hightop depth inlay each Orthopedic footwear, mens shoe, oxford, each Orthopedic footwear, mens shoe, depth inlay, each Orthopedic footwear mens shoe hitop depth inlay each Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthotic) Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthotic) Orthopedic footwear custom shoe depth inlay each Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each Foot, shoe molded to patient model, silicone shoe, each Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each Foot, molded shoe, Plastazote (or similar), custom fitted, each Nonstandard size or width Nonstandard size or length Orthopedic footwear, additional charge for split size Surgical boot/shoe, each Plastzote Sandal, Each Lift, elevation, heel, tapered to metatarsals, per inch Lift, elevation, heel and sole, neoprene, per inch Lift, elevation, heel and sole, cork, per inch Lift, elevation, metal extension (skate) Lift, elevation, inside shoe, tapered, up to one-half in Lift, elevation, heel, per inch Heel wedge, SACH Heel wedge Sole wedge, outside sole Sole wedge, between sole Clubfoot wedge Page 6

7 HCPCS Code L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3600 L3610 L3620 L3630 L3640 L3649 Outflare wedge Metatarsal bar wedge, rocker Metatarsal bar wedge, between sole Full sole and heel wedge, between sole Heel, counter, plastic reinforced Heel, counter, leather reinforced Heel, SACH cushion type Heel, new leather, standard Heel, new rubber, standard Heel, Thomas with wedge Heel, Thomas extended to ball Heel, pad and depression for spur Heel, pad, removable for spur Orthopedic shoe addition, insole, leather Orthopedic shoe addition, insole, rubber Orthopedic shoe addition, insole, felt covered with leather Orthopedic shoe addition, sole, half Orthopedic shoe addition, sole, full Orthopedic shoe addition, toe tap, standard Orthopedic shoe addition, toe tap, horseshoe Orthopedic shoe addition, special extension to instep (leather with eyelets) Orthopedic shoe addition, convert instep to Velcro closure Orthopedic shoe addition, convert firm shoe counter to soft counter Orthopedic shoe addition, March bar Transfer of an orthotic from one shoe to another, caliper plate, existing Transfer of an orthotic from one shoe to another, caliper plate, new Transfer of an orthotic from one shoe to another, solid stirrup, existing Transfer of an orthotic from one shoe to another, solid stirrup, new Transfer of an orthotic from one shoe to another, Dennis Browne splint (Riveton), both shoes Orthopedic shoe, modification, addition or transfer, not otherwise specified ICD-10-CM Diagnosis Code E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E Type 1 diabetes mellitus with diabetic neuropathic arthropathy E Type 1 diabetes mellitus with other diabetic arthropathy Page 7

8 ICD-10-CM Diagnosis Code E Type 1 diabetes mellitus with diabetic dermatitis E Type 1 diabetes mellitus with foot ulcer E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E Type 2 diabetes mellitus with diabetic neuropathic arthropathy E Type 2 diabetes mellitus with other diabetic arthropathy E Type 2 diabetes mellitus with diabetic dermatitis E Type 2 diabetes mellitus with foot ulcer G57.51 Tarsal tunnel syndrome, right lower limb G57.52 Tarsal tunnel syndrome, left lower limb G57.61 Lesion of plantar nerve, right lower limb G57.62 Lesion of plantar nerve, left lower limb G60.0 Hereditary motor and sensory neuropathy G60.3 Idiopathic progressive neuropathy G60.8 Other hereditary and idiopathic neuropathies G61.81 Chronic inflammatory demyelinating polyneuritis G61.82 Multifocal motor neuropathy G61.89 Other inflammatory polyneuropathies I Atherosclerosis of native arteries of right leg with ulceration of ankle I Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot I Atherosclerosis of native arteries of right leg with ulceration of other part of foot I Atherosclerosis of native arteries of left leg with ulceration of ankle I Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot I Atherosclerosis of native arteries of left leg with ulceration of other part of foot I73.00 Raynaud's syndrome without gangrene I73.01 Raynaud's syndrome with gangrene I73.1 Thromboangiitis obliterans [Buerger's disease] I73.81 Other specified peripheral vascular diseases I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity I87.2 Venous insufficiency (chronic) (peripheral) M Felty's syndrome, right ankle and foot M Felty's syndrome, left ankle and foot M Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot M Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot Page 8

9 ICD-10-CM Diagnosis Code M Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot M Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot M Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot M Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot M Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot M Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot M Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot M Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot M Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems M Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems M Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement M Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement M Other rheumatoid arthritis with rheumatoid factor of right ankle and foot M Other rheumatoid arthritis with rheumatoid factor of left ankle and foot M Rheumatoid arthritis without rheumatoid factor, right ankle and foot M Rheumatoid arthritis without rheumatoid factor, right ankle and foot M Rheumatoid bursitis, right ankle and foot M Rheumatoid bursitis, left ankle and foot M Rheumatoid nodule, right ankle and foot M Rheumatoid nodule, left ankle and foot M Other specified rheumatoid arthritis, right ankle and foot M Other specified rheumatoid arthritis, left ankle and foot M Idiopathic gout, right ankle and foot M Idiopathic gout, left ankle and foot M Chronic postrheumatic arthropathy [Jaccoud], right ankle and foot M Chronic postrheumatic arthropathy [Jaccoud], left ankle and foot M Kaschin-Beck disease, right ankle and foot M Kaschin-Beck disease, left ankle and foot M Villonodular synovitis (pigmented), right ankle and foot M Villonodular synovitis (pigmented), left ankle and foot M Traumatic arthropathy, right ankle and foot M Traumatic arthropathy, left ankle and foot M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.31 Unilateral post-traumatic osteoarthritis, right knee Page 9

10 ICD-10-CM Diagnosis Code M17.32 Unilateral post-traumatic osteoarthritis, left knee M Primary osteoarthritis, right ankle and foot M Primary osteoarthritis, left ankle and foot M Post-traumatic osteoarthritis, right ankle and foot M Post-traumatic osteoarthritis, left ankle and foot M Secondary osteoarthritis, right ankle and foot M Secondary osteoarthritis, left ankle and foot M20.11 Hallux valgus (acquired), right foot M20.12 Hallux valgus (acquired), left foot M20.21 Hallux rigidus, right foot M20.22 Hallux rigidus, left foot M20.30 Hallux varus (acquired), right foot M20.31 Hallux varus (acquired), left foot M20.41 Other hammer toe(s) (acquired), right foot M20.42 Other hammer toe(s) (acquired), left foot M20.5X1 Other deformities of toe(s) (acquired), right foot M20.5X2 Other deformities of toe(s) (acquired), left foot M Varus deformity, not elsewhere classified, right ankle M Varus deformity, not elsewhere classified, left ankle M Flexion deformity, right ankle and toes M Flexion deformity, left ankle and toes M Acquired clubfoot, right foot M Acquired clubfoot, left foot M Bunion of right foot M Bunion of left foot M Bunionette of right foot M Bunionette of left foot M21.6X1 Other acquired deformities of right foot M21.6X2 Other acquired deformities of left foot M Unequal limb length (acquired), right femur M Unequal limb length (acquired), left femur M Unequal limb length (acquired), right tibia M Unequal limb length (acquired), left tibia M Unequal limb length (acquired), right fibula M Unequal limb length (acquired), left fibula M Contracture, right ankle M Contracture, left ankle M Contracture, right foot Page 10

11 ICD-10-CM Diagnosis Code M Contracture, left foot M Other instability, right ankle M Other instability, left ankle M Other synovitis and tenosynovitis, right ankle and foot M Other synovitis and tenosynovitis, left ankle and foot M Ganglion, right ankle and foot M Ganglion, left ankle and foot M Other specified disorders of synovium, right ankle and foot M Other specified disorders of synovium, left ankle and foot M Other bursal cyst, right ankle and foot M Other bursal cyst, left ankle and foot M Other bursitis, not elsewhere classified, right ankle and foot M Other bursitis, not elsewhere classified, left ankle and foot M72.2 Plantar fascial fibromatosis M76.61 Achilles tendinitis, right leg M76.62 Achilles tendinitis, left leg M76.71 Peroneal tendinitis, right leg M76.72 Peroneal tendinitis, left leg M Anterior tibial syndrome, right leg M Anterior tibial syndrome, left leg M Posterior tibial tendinitis, right leg M Posterior tibial tendinitis, left leg M77.31 Calcaneal spur, right foot M77.32 Calcaneal spur, left foot M Other acute osteomyelitis, right ankle and foot M Other acute osteomyelitis, left ankle and foot M Subacute osteomyelitis, right ankle and foot M Subacute osteomyelitis, left ankle and foot M Chronic multifocal osteomyelitis, right ankle and foot M Chronic multifocal osteomyelitis, left ankle and foot M Chronic osteomyelitis with draining sinus, right ankle and foot M Chronic osteomyelitis with draining sinus, left ankle and foot M Other chronic osteomyelitis, right ankle and foot M Other chronic osteomyelitis, left ankle and foot M89.8X7 Other specified disorders of bone, ankle and foot M92.61 Juvenile osteochondrosis of tarsus, right ankle M92.62 Juvenile osteochondrosis of tarsus, left ankle M92.70 Juvenile osteochondrosis of metatarsus, right foot Page 11

12 ICD-10-CM Diagnosis Code M92.71 Juvenile osteochondrosis of metatarsus, left foot Q66.0 Congenital talipes equinovarus Q66.1 Congenital talipes calcaneovarus Q66.21 Congenital metatarsus primus varus Q66.22 Congenital metatarsus adductus Q66.3 Other congenital varus deformities of feet Q66.4 Congenital talipes calcaneovalgus Q66.6 Other congenital valgus deformities of feet Q66.7 Congenital pes cavus Q66.81 Congenital vertical talus deformity, right foot Q66.82 Congenital vertical talus deformity, left foot Q66.89 Other specified congenital deformities of feet VIII. REFERENCES TOP American Diabetes Association. Preventive foot care in people with diabetes. Diabetes Care. 2000;23 Suppl 1:S55-S56. Ashford R, Kippen C, Rome K. Interventions for pes planus (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2005;(1):CD Burns J, Landorf KB, Ryan MM, et al. Interventions for the prevention and treatment of pes cavus. Cochrane Database Syst Rev. 2007;(4):CD Clark H, Rome K, Plant M, et al. A critical review of foot orthoses in the rheumatoid arthritic foot. Rheumatology (Oxford). 2006;45(2): Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003;(3):CD Gabriner ML, Braun BA, Houston MN, Hoch MC. The effectiveness of foot orthotics in improving postural control in individuals with chronic ankle instability: A critically appraised topic. J Sport Rehabil. 2015;24(1): Hijmans JM, Geertzen JH, Dijkstra PU, Postema K. A systematic review of the effects of shoes and other ankle or foot appliances on balance in older people and people with peripheral nervous system disorders. Gait Posture. 2007;25(2): Hume P, Hopkins W, Rome K, et al. Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: A review. Sports Med. 2008;38(9): Nordian Healthcare Solutions, LLC (NHS). Orthopedic Footwear. Local Coverage Determination No. L Durable Medical Equipment Medicare Administrative Carrier Jurisdiction J-A; revised January 1, Page 12

13 Papuga MO, Cambron J. Foot orthotics for low back pain: The state of our understanding and recommendations for future research. Foot (Edinb). 2016;26: IX. POLICY HISTORY TOP MP CAC 1/28/03 CAC 1/27/04 CAC 9/28/04 CAC 10/25/05 CAC 3/28/06 CAC 7/25/06 CAC 1/30/07 CAC 3/27/07 CAC 3/25/08 CAC 9/30/08 CAC 11/25/08 CAC 7/28/09 CAC 11/30/10 Consensus review. No change to the policy statement CAC 6/26/12 Consensus review. Benefits information deleted including coverage limits for diabetic shoes. 7/24/13 Admin coding review complete CAC 9/24/13 Consensus 12/20/2013 New 2014 Code updates made. CAC 9/30/14 Consensus review. References updated; no changes to the policy statements. Added ICD Un-ranged ICD-9 and added ICD-10 coding 11/2/15 Administrative change. LCD numbers changed due to NHIC update to ICD 10. CAC 9/29/15 Consensus review. References updated. No change to policy statements. 7/1/16 Administrative Change. LCD references updated from NHIC to Noridian. Administrative Update 12/7/16: New code A9285, A4467 added and end dated code A4466 removed; effective 1/1/17. Admin update 1/1/17: Product variation section updated. New diagnosis codes added effective 10/1/16 CAC 9/27/2016 Removed trusses. Coding organized by orthotic type. Coding reviewed and updated. Effective 6/1/17. Admin update 1/17/18: Medicare variations removed from Commercial Policies effective 1/1/18. CAC 9/26/17 Minor Review. Orthotics separated into four policies. Page 13

14 Foot Orthotics and other Podiatric Appliances Therapeutic Shoes for Persons with Diabetes Ankle-Foot and Knee-Ankle-Foot Orthoses Spinal Orthoses (other than for Scoliosis) Statement added that the provider requesting/ordering the DME should be a provider with whom the member has established a relationship and is involved in the ongoing care of the member and the condition for which the DME/orthotic is prescribed. Coding reviewed. 5/29/18 Consensus Review. Policy and references reviewed with no changes. Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 14